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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411698
Report Date: 11/22/2021
Date Signed: 11/22/2021 03:43:56 PM

Document Has Been Signed on 11/22/2021 03:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ACEVEDO, MARIBELFACILITY NUMBER:
434411698
ADMINISTRATOR:ACEVEDO, MARIBELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 622-6929
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 14TOTAL ENROLLED CHILDREN: 2CENSUS: 1DATE:
11/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Maribel AcevedoTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Janette Cruz met with Maribel Acevedo, Licensee, for unannounced Required – 1 year annual inspection. LPA was granted access to the home by the Licensee. LPA also observed one infant (Licensee's granddaughter), Licensee's two adult daughters and son-in-law present in the home during today's inspection. The Licensee was operating within her capacity and ratio requirements. LPA observed the required postings, including the facility license, near the front entrance to the home. Days and hours of operation are Monday - Friday from 6:30 AM to 6:00 PM. The Licensee, her daughters, Andrea Valencia and Jazmine Vongsa and son-in Law, Jose Sanchez-Ortiz, are the adults residing in the home. There are no active waivers or exceptions for this facility. Licensee has current CPR and First Aid certifications (expiration: 06/07/2022).

LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on 09/30/2021. Licensee has an active Child Care Liability Insurance valid until 1/11/2022. Licensee has the required vaccinations (MMR, Tdap, & flu). Licensee's Mandated Reporter Training for Child Care Workers expires on 04/23/2023. LPA reviewed two children's files which were complete with the required forms.

LPA discussed the safe sleep regulations with the Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. Licensee states that a child will be isolated in the family room of the home if necessary due to illness or communicable disease.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ACEVEDO, MARIBEL
FACILITY NUMBER: 434411698
VISIT DATE: 11/22/2021
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LPA observed the home is clean, orderly, and safe for the day care children. LPA also observed no fireplace and no stairs inside the home. There is a barricaded open face heater in the living room. The Licensee has the living room, family room, bathroom by the hallway and the patio primarily used for the day care. Off limit areas in the home: all bedrooms and attached garage. LPA observed a fenced backyard and no bodies of water. Off limits: outside backyard.

LPA observed a fully charged 3A40BC fire extinguisher and working smoke/carbon monoxide detectors. The Licensee states that she does not have any weapons in the home. The Licensee has four small dogs in the home that licensee states are kept away from children. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. All poisons are stored in high shelves. The Licensee states that she does not administer medication to the day care children.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Supervision of children was discussed with Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children without a fully qualified adult assistant present in the

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ACEVEDO, MARIBEL
FACILITY NUMBER: 434411698
VISIT DATE: 11/22/2021
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home at any time. Licensee states that she does not transport day care children. The Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.


To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to [email protected]. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.


Exit interview conducted and report was reviewed with the Licensee, Maribel Acevedo.

As a result of todays inspection, a deficiencies cited on the following page.



A Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2021 03:43 PM - It Cannot Be Edited


Created By: Janette Cruz On 11/22/2021 at 02:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ACEVEDO, MARIBEL
FACILITY NUMBER: 434411698

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensee's adult son-in-law, Jose Sanchez-Ortiz, who resides in Licensee's home, does not have a criminal record and child abuse index clearance. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2021
Plan of Correction
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 The Licensee submitted a written statement to the Department on 11/22/21 indicating that they understand that all adult(s) must obtain the required criminal record and child abuse index clearances prior to working or residing in the home. Licensee will submit criminal record clearance of son-in-law by POC date.
Civil penalty of $500 assessed today (see LIC 421BG). The Licensee must provide copies of this report to parents/guardians of children in care at this facility and to parents/guardians of children newly enrolled at this facility during the next 12 months per the AB633 requirements.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Diana Stephenson
LICENSING EVALUATOR NAME:Janette Cruz
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021


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Document Has Been Signed on 11/22/2021 03:43 PM - It Cannot Be Edited


Created By: Janette Cruz On 11/22/2021 at 03:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ACEVEDO, MARIBEL
FACILITY NUMBER: 434411698

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102369(b)(9)
Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above, Licensee did not obtain tuberculosis clearances for daughter, Jazmine Vongsa and son-in-law Jose Luis Sanchez Ortiz, who both reside in Licensee's home, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2021
Plan of Correction
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Licensee agreed to submit negative tuberculosis test for the two adults by POC date 12/07/2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Diana Stephenson
LICENSING EVALUATOR NAME:Janette Cruz
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021


LIC809 (FAS) - (06/04)
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